Provider Demographics
NPI:1114512092
Name:BELLMORE, JORDAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BELLMORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8775 WINDING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MILLERSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49759
Mailing Address - Country:US
Mailing Address - Phone:989-733-0008
Mailing Address - Fax:
Practice Address - Street 1:109 S 13TH AVE
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1609
Practice Address - Country:US
Practice Address - Phone:989-356-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010435363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant